Renal Dysfunction due to an Arteriovenous Fistula in a Transplant ...

EDITORIAL Tomas

Berl, Editor

Denver,

William

CO

Henrich

Dallas,

DESCRIPTION

COMMITTEE

Mark

TX

Paller

Minneapolis,

OF THE NEPHROLOGY WASHINGTON

TRAINING SCHOOL

Fred Silva Oklahoma

MN

CIty,

OK

PROGRAM AT THE UNIVERSITY OF MEDICINE

OF

The nephrology training program at the University of Washington has trained more than 150 fellows over 30 yr. starling in the l9#{243}Os under Dr. Belding Scribner. Fellowship training is supervised by 14 full-lime faculty under the direction of Dr. William Couser. with research interests that range from clinical research to cell and molecular biology. The program currently has 10 fellows in various stages of clinical and research training. The clinical training program accepts four fellows each year. The program selects the best candidates available and may accept individuals interested only in clinical training as well as candidates who seek advanced training In clinical or basic research in preparation for academic careers. Clinical fellows spend 3 months each on the renal consult services at the University of Washington Medical Center, and the Seathe VA Hospital. and Harborview Medical Center and on the kidney and kidney-pancreas transplant services at the universily. Addilionai exposure is provided to chronic hemodialysis and peritoneal dialysis at the Northwest Kidney Center, bone marrow transplant paflents at the Fred Hutchinson Cancer Pesearch Center. and pediatric nephrology at Children’s Hospital Medical Center. Weekly didactic teaching

conferences

conferences.

consist

of clinical

as well as a Visiting

case

Professor

discussions,

program.

Fellows

journal

clubs,

attend

clinic

renal

biopsy

conferences.

one half-day

each

and

research

week.

Pesearch activities Include immunologic and other glomerular diseases, diabetic nephropathy, hypertension, metabolic bone disease, acute renal failure, transplantation, and dialysis therapy. Fellows choosing to pursue basic research training generally enter a 3-yr training program that includes experience in both applied nephrology science under the direction of a nephrology faculty member and basic science training under the direction of selected faculty members in the basic sciences. Basic research training is supported by NIH training grants in nephrology and in molecular medicine. The University of Washington has also been designated a George M. O’Brien Kidney Pesearch Center by the NIH. Fellows choosing to pursue clinical research training enter a structured training program conducted jointly by the DMsion of Nephrology and the School of Public Health designed to prepare individuals for an academic career focused on clinical research.

Renal Dysfunction due to an Arteriovenous Transplant Recipient1 Karen

L. Harrison,

Hanh

V. Nghiem,

Douglas

M. CoIdweII,

and

Fistula in a

Connie

1. Davis2

remain

asymptomatic

K.L,

tension,

and/or

raphy;

however,

H,V. Nghiem, ogy, Universily Seattle, WA

sive and nonnephrotoxic, has become tool In the localization of a postblopsy postbiopsy AVF are asymptomatic and neously. Conversely, AVF may enlarge symptomatic, requiring embolizatlon

Harrison. CL. Davis, Department of Medicine, Division of Nephrology and Division of Transplantation, Universily of Washington School of Medicine, Seattle, WA

(J. Am.

Soc.

Nephrol.

ABSTRACT Arteriovenous renal biopsy 1 Poc&ved

D.M. Coldwell, of Washington

Transplantation

17. 1993. ACcepted to Dr. C.L

Services,

1959

Davis,

March

Un!vorslly

NE Pacific,

P043,

Copyright

1300

percutaneous Flstulae may

10, 1994.

of the American Soctely of Nephrology C by the Arner$can Society of Nephrology

Seattle,

to hematuria,

insufficiency. of an AVF has traditionally been

hyper-

The Identification made with anglog-

ulfrasonography,

which

is less invaa valuable fistula. Most close sponta-

and to

become reverse

or

prevent a renal

ol Washington

1046.6673/0506.01300$03OO/O

Journal

of RadiolMedicine,

of

5:1300-1306)

flstulae (AVF) occur after In up to 1 8% of patients.

September

2 Correspondence

1994;

Department School

or lead

renal

Medical

WA 98195.

Center.

complications. A case of renal Insufficiency In transplant recipient due to a postbiopsy AVF is presented. Spontaneous closure of the AVF resulted in the resolution of renal insufficiency. One must suspect an AVF when renal insufficiency occurs in an allograft after biopsy. Further study is needed to identify ulfrasound characteristics tory of postbiopsy Key Words:

Postbiopsy,

that

will

predIct

the

natural

his-

AVF. complication,

color

flow

Doppler

ultrasound

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A

rteriovenous

fistulae

(AVF)

are

uncommon of percutaneous Most AVF are regress: howhematuria, and an

but well-known complication native and transplant renal biopsy. asymptomatic and often spontaneously ever, AVF may result in hypertension, renal insufficiency ( 1- 1 3). We present renal transplant recipient who developed

a

cadaveric

insufas demonstrated by color flow Doppler ultrasound. Three days later, the serum creatinine had returned to baseline and angiography showed resolution of the fistula. The differential diagnosIs of posttransplant renal dysfimction should include AVF, in addition to cycbosporine toxicity. rejection, obstruction, and recurrent or cle novo renal disease. ficiency

secondary

CASE

to a large,

renal

postbiopsy

AVF

REPORT

A 27-year-old white woman developed end-stage renal failure as a result of chronic pyebonephrltis secondary to ureteral reflux. She received a six-antigen-matched living donor kidney from her mother in May 1990 that failed in June 1992 secondary to antineutrophil

cytoplasmic

antibodies

(ANCA)-nega-

tive, antiglomerular basement membrane-negative crescentic glomerular nephritis. Hemodialysis was instituted and continued until March 1993, when she received a cadaveric renal transplant. Because of prolonged donor cardiopulmonary resuscitation, the graft was biopsied after procurement with a 14-gauge Trucut needle. No pathologic abnormalities were found, and the kidney was transplanted into the patient’s left iliac fossa. Immunosuppression consisted of induction OKT3, azathioprine, and prednisone. The immediate postoperative Tc-99m MAG-3 renal scan was consistent with acute preservation injury and demonstrated

slightly

decreased

activity

at

the

lower

pole

without evidence of obstruction or urine leak. Color flow Doppler ultrasound performed 1 and 3 days posttransplantation demonstrated arterial flow to all regions of the graft. Subsequently, renal function improved and cycbosporine was initiated on postoperative day 10. The serum creatinine continued to fall, reaching 21, with

a nadir a morning

186

ng/mL

and

furosemide.

and

of

1 .8

mg/dL

on

postoperative

day

12-h trough cyclosporine level of a normal blood pressure on isradipine Seven days later, she was noted to blood pressure, an increased creati-

have an elevated nine of 2.5 mg/dL, and a cycbosporine trough level of 39 1 ng/mL. She denied fever, myalgias, change in urine output, or alteration In medication schedule. Her physical examination was significant for hypertension without orthostatic changes and the absence of allograft tenderness or bruit. Peripheral extremity edema, noted the previous week, had improved. Unnalysis demonstrated no pyuria, hematuria, or proteinunia. Color flow and pulsed Doppler ultrasound of the allograft revealed a focal (3-cm) hypoechoic lesion in

the

Doppler

Journal

lower

pole

that

waveform

of the American

had

the

characteristic

Society

color

flow

of an

of Nephrology

pattern AVF with

and re-

et al

duced perfusion to the remainder of the allograft parenchyma (Figure 1). Because of renal insufficiency and large AVF size, angiographic embollzation was recommended. The patient, however, declined intervention until the following week, and she was discharged on a reduced dose ofcyclosponine. Three days later, intra-artenial digital subtraction angiography revealed

normal

allograft

vascularity

without

evidence

of an AVF (Figure 2). Repeat color flow Doppler ultrasound showed resolution of the previous abnormalities, indicating spontaneous closure of the AVF. Concurrently, the serum creatinine had returned to 1.9 mg/dL, whereas the trough cyclosponine level remained elevated at 398 ng/mL despite a lowered dose. Ultrasound examinations performed 2 wk to 9 months later continued to show normal monphobogy of, and vascular flow to, all regions of the albograft (Figure 3).

DISCUSSION Complications of percutaneous needle biopsy indude gross hematunia, perirenal hematomas, aneurysms, and AVF (1-13). AVF result from simultaneous damage to the walls of an adjacent artery and vein, causing arteniallzed blood to be shunted into the low-pressure venous system (1 ,8). Clinically, AVF may be

asymptomatic

or associated

hematuria,

clot-induced

hypertension,

and

turia

associated

wIth

rarely, an

with a localized bruit, urinary tract obstruction, renal insufficiency. HemaAVF develops when Intrare-

nab vessels communicate with the collecting system (1 1 , 13). Severe hemorrhage may result In clot formation with secondary uretenal obstruction and renal insufficiency (1 1 , 13). The shunting of blood through

the fistulae and away from been postulated to cause increased unilateral renin and renal insufficiency. however, have not been cause ofdilution from the flstulae

demonstrated,

large

perhaps

blood

flow

through

who

have

flow

through

hematunia, has been

AVF

in patients

hypertension, estimated

and by

shunts

flow

to the

venous

renal

angiography,

tion, or hippuran clearance techniques 60 to 82% of the total unilateral renal Lower vascular resistance in the venous AVF

be-

the

(8,10,14).

Blood oped ciency

the renal parenchyma has renal ischemla, followed by production, hypertension, Elevated renal vein renins,

system

devel-

insuffidye

dilu-

to approach flow (2,8,9). outflow of the and

away

from

the peripheral renal arterial bed, resulting in decreased perfusion to the remaining parenchyma distal to the fistula. Perfusion to the remaining renal parenchyma has been shown to be reduced by as much as 28 to 85% (8,9, 14, 15). ThIs vascular steal phenomenon has been accompanied by decreased (51CrJEDTA clearance when compared with the contralateral kidney (9). Thus, in the setting of a single functioning kidney. a detectable decrease in renal function may occur. It can also be hypothesized that elevated cycbosponine levels may aggrevate AVF-induced renal ischemia

by compounding

Intrarenal

vasoconstnlction

and

1301

Renal Aliograft

Fistula

Figure 2. Infro-arterlal onstrates could

no evidence have

ciency

been

in our

The

a factor

contributing

incidence diagnosis

ofdiagnostic

study

AVF to be quite severe hematunia,

studied

evaluated.

was revealed 18%

Figure 1 Color flow Doppler sonography of the renal allograft. (A) Gray scale imaging demonstrates a focal (3-cm) hypoechoic lesion (markers) in the lower pale of the renal .

1302

(16).

The when

to

AVF

on

flable

insuffi-

incidence

the

the angiogram. the incidence

patients in

increased was

and

of

patients who developed or renal insufficiency

immediately after 1 1% incidence

angiography

mode

1). Traditionally,

Asymptomatic studies

is unknown

the

has been reported

low, but only hypertension,

Prospective

performed a 9

(3, 1 7).

to renal

ofpostbiopsy depends

gold standard for diagnosis Early retrospective studies

were

dem-

patient.

precise the

because timing

subfractlon digital angiography of vascular abnormality.

were

which

angiography

native

renal

of

fistula

to

between

performed

not

biopsy

formation

12

and

1 day

to

6

graft. (B) Color flow Doppler of the graft. An AVF is evident as an area of intense and mixed red and blue color paffern, suggesting high velocity and disturbed flow (arrows). Flow in the remainder of the graft Is diminished. (C) Pulsed Doppler demonstrates turbulent flow of the AVF with spectral broadening of the Doppler waveform and signals above and below the baseline.

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vide

noninvasive,

nosing

and

nonnephrotoxic

monitoring

methods

postbiopsy

for

vascular

et al

diag-

complica-

tions (6,7). Duplex ultrasound combines real-time gray scale imaging with pulsed Doppler imaging. Color flow Doppler ultrasound combines B-mode gray scale imaging with a color map of blood flow Doppler frequency shifts. On color flow ultrasound, an AVF is characterized

as

an

area

of intense,

mixed

color

pat-

tern resulting from high-velocity flow and disturbed flow within the fistula (5-7). With pulsed Doppler, the hemodynamic effect of an AVF is seen as a highvelocity, low-pulsatillty arterial waveform in the artery leading to the fistula, turbulent flow within the fistula and spectral broadening and flow signal above and below the baseline, and arterialization of the vein arising from the fistula (Figure 1) (6,7, 15). AVF have been identified by color flow imaging and duplex Doppler in 4 to 17.5% of allogralts 1 day to 6 months after

biopsy

(6, 15).

Resolution

occurs

in

approxi-

mately 64% on follow-up ultrasonography within 2 to 50 days (15). Color flow Doppler ultrasound has been shown to be more sensitive than duplex Doppber ultrasound for the diagnosis of AVF, as assessed by a comparison with intra-artenial digital subtraction angiognaphy (6). H#{252}bsch et aL found six vascular abnormalities by color Doppler after 10 1 native renal biopsies (6). Four abnormalities AVF, whereas

identified Doppler without sult.

were two

However,

if not

Doppler why the

months of 1 5

immediate

after patients

biopsy (1-4). LundstrOm without evidence of

postbiopsy

fistula 1 day to 6 wk AVF may not develop but that several days

angiogram later

(3).

immediately may

be

showed an AVF

nose postbiopsy AVF, comparing simultaneous

were ThIs

found

to have

demonstrates

at the required

that

time for

that 3 on the

the

of biopsy artenio-

venous connection to form. When angiography was repeated 6 wk to 4 yr after the diagnosis of an AVF, 33 to 90#{176}/oof fistulae had resolved (1-3). Thus, the timing of the diagnostic study influences the incidence of reported AVF fonmation and may explain the timing of the detection of the AVF in our patient, 28 days postbiopsy and 25 days after the last negative ultrasound examination. Duplex and color flow Doppler ultrasonognaphy pro-

Journal

of the

American

Society

of Nephrology

a

Doppler ultrasound the precise predictive unknown. The resolution of through clot formation. scnlbed clot formation

formation are no

have identifying

curateby

predict

Large ullary

are

to

be

not

needle

This

may

prospective

studies

angiography and color flow have not been performed. Thus, value of ultrasound diagnosis is fistulae Morton within

been ultrasound

is thought to occur and Charboneau dean AVF that subse-

color events

flow Doppler 6 days leading to thrombus

elucidated.

Presenfly,

characteristics

spontaneous

complications needle

examination.

not seen on the first two in our patient. Thus, alultrasound is a promising method by which to diag-

large-scale

quentiy resolved on repeat later (5). The precipitating

future

angiography

Duplex Doppler To date, color flow postbiopsy lesions or false-negative rethat very small AVF may searched for at the time

carefully

ultrasound AVF was

ultrasound examinations though color flow Doppler and increasingly sensitive Figure 3. Repeat color flow Doppler sonography ofthe renal allograft. (A) Color flow Doppler demonstrates normal color flow pattern to all areas of the allograft. (B) Pulsed Doppler demonstrates normal spectral waveform.

by

it is possible

go undetected of color explain

Identified

were aneurysms. only one abnormality. has accurately located a reported false-positive

fistula

there that

closure

ac-

or risk

of

(15).

size, penetration, with

lack

of radiologic and

sclerotic

guidance,

med-

blood vessels AVF formation

associated an Increase in 2). The smaller gauge needles (16 or 18 gauge) used with the automated biopsy guns and ultrasound needle guidance during biopsy have decreased AVF development after transplant and native renal biop(Table

1303

Renal Allograft

TABLE

Fistula

1 Incidence

of AVF after

.

Authors

percutaneous Type of Bioy

(Ref. No.), Yr

and Wiener (1), 1965 Ekelund and Undholm (2), 1971 Meng and Elkin (1 7), 1971 Lundstr#{244}m(3), 1972 K#{244}hler and Edgren (4), 1974 HUbsch et al. (6), 1990 Deane et al. (15), 1992 Renowden et aL (7), 1992 Abbreviations:

d. day;

patients

(pts)

underwent

TABLE

2. Risk factors

mo, month; unilateral

immed. or biateral

influencing

immediate;

biopsya

58 ptsb 48 18 140 50 101 p15 126 pts 208 wk. week;

percutaneous

biopsy.

in parentheses

Numbers

are references.

precipitate symptoms postbiin increased investIgation of vascular abnormalities (7). Asymp-

and detection tomatic flstulae have most frequently been located 0.4 to 0.8 cm from the renal surface (7). Biopsies performed on procured kidneys before transplantation, as occurred in this case, also result in increased AVF formation, perhaps because ofthe lack ofvisual guidance and deep needle penetration (16). Multiple renal biopsies into a kidney have reportedly resulted more frequently in AVF: however, the risk of fistula per biopsy pass has not necessarily been increased (6,7, 19). Patients with hypertension and nephrosclerosis are at increased risk for postbiopsy AVF formation (1-4, 12). Biopsies performed in transplanted kidneys beyond 1 yr after transplantation have also resulted in more frequent AVF formation and are less likely to close spontaneously, possibly because of cycbosporine artenlobopathy and fibrosis (13,15). Treatment options for AVF include observation, artenlal embolization, and surgical ligation (Table 3). small Doppler

has

been

reported

(< 1.8 cm), asymptomatic ultrasound examinations every 3 to 6 months because increasing the risk for symptom

1304

anglo. C

One

2d-1O mo 5d-13 mo Immed lmmed-5wk 2-7d 1-30d 1-4d 1_7dc

ofAVF

33 71 NS 67 NS NS 43 NS

Anglo

Doppler;

NS. not

stated.

for

fistula management examinations into not been performed. arterial embolization

have

30% ofthe renal malities in the

b

Fifty-eight

are

the

available

natural

his-

mass (1 1, 12, 14,20). Perfusion remainder of the kidney reverse

abnorafter

successful embolization (14). Surgical ligation should be reserved for lesions unsuccessfully embollzed or those causing massive bleeding. In summary, renal insufficiency may be caused by biopsy-induced AVF due to the shunting ofblood away from the renal parenchyma. The risk of symptomatic AVF after biopsy is more pronounced in the single transplant kidney and occurs more often If the patient is hypertensive,

needle

penetration

is deep,

or

larger

gauged

needles are used. Renal insufficiency that begins or worsens postbiopsy should be investigated by color flow Doppler in order to identify a hemodynamically significant AVF. Most clinically symptomatic AVF will be Identified by color flow Doppler. Small fistulae less than 1 .8 cm in diameter may be monitored by serial ultrasound examinations If the patient Is asymptomatic.

eter

may

Color should be repeated lesions may enlarge, development (13).

long

as

be appropriate AVF (5, 13).

Angio Angio Anglo Anglo Anglo CFD and CFD CFD

Transcatheter by a superselective technique is the treatment of choice for symptomatic fistulae in both native and transplant kidneys (1 1-13,20). A variety of embolization materials have been used in the management of AVF, including Gelfoam and stainless steel or platinum coils (11,12,14,20). The supersebective embolization technique limits the infarction of normal tissue to the area supplied by the arterial source of the fistulae. The estimated tissue loss postembolization by technitium and iodine scans or angiography has been found to be between 0 and

for

to

Spontaneous Regression (%)

Diagnostic Method

angiography; CFD. coior flow patient diagnosed at 4 mo.

tory

more frequently therefore resulting

Observation

16 15 11 11 18 4 17.5 7.2

mal guidelines because detailed

sies (18, 19). Early reports of native biopsies suggest that AVF are more likely to occur in the medulla (2,4,8,9). In allograft recipients, most symptomatic AVF have been found more than 1 .9 cm from the renal capsule. suggesting that biopsies reaching the medulla opsy,

Time to AVF Diagnosis

More definitive treatment should be considered if the fistula enlarges or becomes symptomatic with hypertension, hematunia, or renal insufficiency. This case, however, ifiustrates that even large symptomatic fistula may close spontaneously. Currently, only infor-

AVF formation0

Hypertension (2, 4, 12) Nephrosclerosis (2, 12) Fibrosis (12) Arterlolopathy (12) Cenfral or Medullary Biopsy (2, 4, 7) Larger Needle (14 gauge) (18) Lack of Ultrasound Guidance (16) a

Incidence of AVF (%)

No. of Biopsies

NatIve NatIve NatIve Native Native Transplant Transplant Transplant

Benneft

a

renal

Fistula

also the

monitored

patient

remains

more, observation has mild renal bleeding,

as

larger

be

may be insufficiency

in the

case

than

by

1.8

close

cm

in diam-

observation

asymptomatic.

as

Further-

appropriate 11 the patient or hypertension without

presented.

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TABLE 3. Suggested Clinical

management

of AVF

Presentation

RiSkb

0

Asymptomatic

1.8 cm

Asymptomatic

Enlarging

Observe with CFDC every 3 months (5) Observe with CFD each month 1. Observe each week (13)

or not resolving

2. Embollzatlon Symptomatic

1.

Hypertension Renal insufficiency Hematuria

Embollzatbon

2. Observe

(1 1-13, 20)

each

week?

Minimal Unknown,

may

enlarge/bleed

1. Unknown, hypertension. failure. bleedlng/hematuria 2. Anglogram-Induced infarction 1. Anglograrn-Induced infarction

Hematurla with obstruction

2. Ugatlon

Hemorrhage

3. Removal

3. Loss of graft

.

Options

b

Risk of foiiowlng

for management

management

C

CFD, color flow

Doppler.

of AVF

depending

on AVF size and/or

symtpoms.

plan.

or progressive symptoms, however, should lead to fistula embolization. In conclusion, we present a case of renal allogralt dysfunction secondary to an AVF that subsequently closed spontaneously. The AVF was caused by a biopsy performed at the time of procurement. Cyclosponine toxicity was unlikely as the cause of the patient’s renal dysfunction because renal function improved with further diuresis and a consistently high cyclosponine level after fistula closure. Cyclosponine toxicity,

biopsy.

AVF

however, ischemia.

may Overt

have exacerbated rejection was

AVF-induced

severity,

and

must

natural

suspect dysfunction

an

history AVF occurs

of

when after

postbiopsy

or

new

thank Amy preparation.

John

for her expert

secretarial

and

Journal

AR,

aneurysm:

Wiener SN: Intrarenal A complication

of the American

Society

assistance

arterlovenous of percutaneous

of Nephrology

5.

6.

7.

8.

9.

AiR

L, Lindholm

739-743. in

REFERENCES 1 . Bennett

4.

10.

ACKNOWLEDGMENTS The authors manuscript

3.

fistulae.

persistent biopsy.

1965:95:372-382. T: Arterlovenous fistubae following percutaneous renal biopsy. Acta Radlol 1971; 11:38-48. Lundstr#{246}m B: Intrarenal arteriovenous fistulas. Acta Radiol (Suppl) 1972:321:32-49. K#{246}hlerR, Edgren J: Angiographic abnormalities following percutaneous needle biopsy of the kidney. Acta Radlol (Diag,J 1974:15:515-527. Morton MJ, Charboneau JW: Arteniovenous fistula after biopsy of renal transplant: Detection and monitoring with color flow and duplex ultrasonography. Mayo Clin Proc 1989:64:531-534. H#{252}bsch PJS, Mostbeck G, Barton PP. et a!.: Evaluation of arteriovenous fistulas and pseudoaneurysms in renal allografts following percutaneous needle biopsy: Colorcoded Doppler sonography versus duplex Doppler sonography. J Ultrasound Med 1990:9:95-100. Renowden SA, Blethyn J, Cochlin DL: Duplex and cobour flow sonography in the diagnosis of post-biopsy arterlovenous flstulae in the transplant kidney. Clin Radlol 1992:45:233-237. Ekelund L, Gothlin J, Lindholm T, Lindstedt E, Mattsson K: Arteriovenous fistulas followIng renal biopsy with hypertension and hemodynarnic changes: Report of a case studied by dye-dilution technique. J Urol 1972; 108: 373-376. Lindg#{226}rdh G, Lindqvist B, Lundstrom B: Renal arterlovenous fistula followIng puncture biopsy: A hemodynamic and functional study in four cases. Scand J Urol Nephrol 1971:5: 18 1-189. O’Brien DP, Parrott TS, Walton KN. Lewis EL: Renal arterlovenous fistulas. Surg Gynecol Obstet 1974:139:

2. Ekelund

renal

also an unlikely cause of renal dysfunction because her renal function improved without added immunosuppressive treatment. Fistulae of this size producing renal insufficiency may have a significant risk of bleeding, and therefore, embolization should remain a possible treatment option. However, this case supports close observation, including color flow Doppler ultrasonography as another alternative. Further prospective postbiopsy investigations with noninvasive ultrasound examinalions are warranted to determine the incidence,

allograft

.

failure

a

One

(1 1-13, 20)

renal

2. Possible massive bleeding, progressive renal failure 1 Angiogram-Induced infarction 2. Bleeding/infarction

1 Embolizatlon

Symptomatic

Renal

of al

fistula renal

1 1 . Benoit G, Charpentier B, Roche A, Bellamy J, Mohamedi D, Fries D: Arteriocabyceal fistula after grafted kidney biopsy: Successful management by selective catheter embolization. Urology 1984:24:487-490. 12. Lawen JG, Van Buren CT, Lewis RM, Kahan BD: Artenlovenous fistulas after renal allograft biopsy: A serious complication in patients beyond one year. Clin Transplant 1990:4:357-369. 13. H#{252}bschP, Schurawltzki H, TraindI 0, Karnel F: Renal

1305

Renal Allograft

14. 15. 16. 17.

1306

Fistula

allograft arteriovenous fistula due to needle biopsy with late onset of symptoms-diagnosis and treatment. Nephron 1991:59:482-485. Winkler J, Neuman-Levin M, Boner G: A successful treatment of an intravenal arteniovenous fistula by percutaneous embolization. JAMA 1991:265:631-632. Deane C, Cowan N, Giles J, et at.: Arteriovenous fistulas in renal transplants: Color Doppler ultrasound observations. Urol Radiol 1992:13:211-217. Diaz-Buxo JA, Donadlo JV Jr: Complications of percutaneous renal biopsy: An analysis of 1 ,000 consecutive biopsies. Clin Nephrol 1975:4:223-227. Meng CH, Elkin M: Immediate angiographic manifesta-

18.

19. 20.

tions of latrogenic renal injury due to percutaneous needle biopsy. Radiology 1971:100:33-341. Mahoney MC, Racadlo JM, Merhar GL, First MR: Safety and efficacy of kidney transplant biopsy: Tru-cut needle vs sonographically guided biopty gun. AiR 1993:160: 325-326. Tung KT, Downes MO, O’Donnell PJ: Renal biopsy in diffuse renal disease-Experience with a 14-gauge automated biopsy gun. Clin Radiol 1992:46:111-113. Orzel JA, Coidwell DM, Eskndge JM: Superselective embolization for renal hemorrhage with a new coaxial catheter and steerable uidewire. Cardlovasc Intervent Radlol 1988; 1 1 :343-34g.

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